There's a Morning-After Drug to Prevent HIV Infection

At 9:30 p.m. on Friday, April 18, Michelle Lee (not her real name) left a swimming pool party at an apartment complex in The Woodlands, strolled a couple blocks to her SUV wearing only flip-flops and a two-piece bathing suit with a towel wrapped around it and opened the driver's side door when a strange man suddenly gripped her throat from behind, told her to shut the fuck up, shoved her inside the car onto her stomach and raped her with the door left open.

"I was paralyzed," says Michelle, her hands trembling as she recounts the incident. "My body couldn't do anything."

Michelle knows little about her attacker, only that he was African American and smelled like sweat. "I saw his face," she says, "but don't remember it."

A 32-year-old attorney who has worked on numerous sexual assault cases, Michelle knew better than to go home, bathe and fall asleep, but that's exactly what she did. "I wanted to forget about it," she says. "I wanted to get clean."

It took 24 hours before Michelle could finally cry and admit to herself that she had been raped. She said it aloud. Feeling inexplicably guilty, shameful, she did not want to tell friends or family. But she had to tell somebody.

So she called a national rape organization she knew about through work, which referred her to the Houston Area Women's Center's sexual assault hotline. A counselor there repeatedly instructed Michelle to report the incident to police, even going so far as to say that she might not be able to receive medical care unless she filed a police report.

This made no sense to Michelle, who was adamant about not telling authorities since she had known victims of violent crimes whose cases dragged on for years. "I didn't want this cloud over me for the rest of my life," she says.

As the night wore on, Michelle became increasingly panicked that she might have contracted HIV or some other sexually transmitted disease. She typed "HIV test" into Google on her home computer in Humble and stumbled upon a San ­Francisco-based Web site that described a month-long antiretroviral drug treatment called post-exposure prophylaxis.

PEP, she learned, is an emergency medical treatment commonly used to protect people exposed to the human immunodeficiency virus by preventing the infection from taking hold in the body. The three-drug combination includes the same toxic medication given to people with AIDS.

But the drug regimen must be initiated right away, the Web site warned. It's not effective in aborting HIV if begun more than 72 hours after the incident.

"I needed this PEP like I needed oxygen," Michelle says.

And the clock was ticking.

At 11 a.m. on Sunday, April 20, Michelle arrived at Memorial Hermann Northeast Hospital in Humble. She wasn't interested in getting her blood tested since it was too soon to verify an infection. Nor was she concerned about being pregnant since she uses long-term birth control. And she didn't care to speak with a rape counselor since she already did that.

All she wanted was the PEP.

But the intake nurses insisted that no such drugs exist, according to Michelle. They told her there is no way to ward off HIV after being exposed.

Michelle waited in the emergency room for seven hours without ever seeing a doctor. "I thought, 'Fuck it; fuck it; time's ticking away. I don't want to deal with these people.'" And she left.

She spent the night with her 38-year-old boyfriend of ten months, who remains the only person close to her that she has confided in about the assault. He told her to call police, that they could still inspect her car. She refused.

The next morning, Michelle went to work at her office in downtown Houston. More than 48 hours had passed since the rape. She still had time to act.

She called Planned Parenthood of Houston and Southeast Texas. A counselor put her on hold, then told her nobody there knew of any such drug regimen. This was confirmed by Laura Leon, a spokeswoman for the agency.

The Planned Parenthood counselor advised Michelle to contact The Schrader Clinic, apparently unaware that Dr. Shannon Ray Schrader, who is well known in the Houston area for treating AIDS patients, last year stopped accepting most new patients.

At this point, Michelle considered flying to San Francisco for treatment since it seemed nobody in Houston's medical community could help her.

In fact, the federal government since 1996 has recommended PEP for healthcare workers accidentally exposed to infected blood or needles. In 2005, the national guidelines were expanded to include people exposed to HIV through rape, drug use and unsafe sex.

The national guidelines, which call PEP "an important safety net to reduce the risk of HIV infection," were developed by the U.S. Centers for Disease Control and Prevention, the Food and Drug Administration, the Health Resources and Services Administration and the National Institutes of Health.

The United Nations also recommends PEP as part of the basic package of emergency care for rape survivors.

Using antiretroviral drugs within hours of exposure may inactivate the HIV virus and prevent it from migrating to lymph nodes, reproducing in cells and spreading into the bloodstream. Since HIV takes about three days to reach the lymph nodes, there's a small temporary window when the infection may be blocked.

The sooner the drug treatment is started, the more likely it is to interrupt HIV transmission.

PEP does not work 100 percent of the time, and failure is often attributed to a delay in receiving treatment. But human and animal studies as well as findings from case studies and public health registries show PEP can significantly reduce the risk of HIV transmission, says CDC spokeswoman Nikki Kay.

In fact, PEP is associated with an 80 percent reduction in risk of HIV infection among healthcare workers exposed to the virus on the job, according to data compiled by the CDC. Providing antiretrovirals to HIV-infected women during labor and delivery and to newborns immediately after birth has been shown to cut risk of mother-to-child transmission by about 50 percent.

Every rape intake center in the country should at least inform rape victims about the potential benefits of PEP, says Dr. Amy Kindrick, infectious diseases specialist at the University of California, San ­Francisco.

"Why providers are not informed about PEP continues to be a mystery to me," says Kindrick. "It hasn't been absorbed into the standard of care consistently."

Cities such as Boston, Providence, Los Angeles and San Francisco have been home to PEP clinics for nearly a decade. The New York State Department of Health in 1998 began recommending PEP for rape victims whose assailants can't be found.

In Houston, where three people contract HIV every day, it's a totally different story.

Kathy Barton, spokeswoman for the city of Houston's Department of Health and Human Services, which provides testing and information for HIV prevention, told the Houston Press that she had never even heard of PEP.

After consulting with some doctors, Barton said the city does recommend PEP for occupational exposures but not post-rape. When informed that the federal guidelines were expanded in 2005 to include rape victims, Barton said, "I don't know that we have looked at this since 2005."

Barton added: "We don't want [PEP] to simply become like the morning-after pill, because it gets expensive."

The CDC expresses a similar concern, advising that "PEP is not a substitute for abstinence, mutual monogamy, consistent and correct condom use, use of sterile needles to inject drugs and other behaviors that can help avoid HIV exposure in the first place."

But various studies have shown that increased awareness and availability of PEP does not lead to an increase in risky behavior. PEP is a 28-day commitment, and the drugs often produce severe short-term side effects including intense nausea, fatigue, headaches and hallucinations.

Last summer, a new law went into effect in Texas establishing requirements for hospitals offering emergency services for survivors of sexual assault. These include a private area for victims to await treatment and "access to appropriate prophylaxis for exposure to sexually transmitted ­infections."

Michelle says she was offered neither during her visit to Memorial Hermann Northeast.

Another provision in the new law states that rape survivors must be provided "a forensic medical examination...if the examination has been approved by a law enforcement agency."

It is this passage that may have been misinterpreted by local rape counselors and emergency-room nurses who told Michelle she had to file a police report to receive medical care.

Ann Brimberry, a Memorial Hermann spokeswoman, wrote the Press in an e-mail: "All victims of sexual assault that present to a Memorial Hermann Emergency Center are seen and offered treatment whether a police report is filed or not."

But when the Press called Memorial Hermann Northeast, an emergency-room nurse contradicted this. "You don't just walk in and get treatment; it's a long process," said the nurse, who asked not to be identified since she did not receive permission to speak with a reporter. "Police has to be notified; we have to have a case report number."

At 1:15 p.m. on Monday, April 21, Michelle left work to go stand in line at Legacy Community Health Services on West­heimer in the Montrose neighborhood. She learned about Legacy through her gay friends after lying that she needed to refer a pro bono client to a good HIV clinic.

"We're sort of known underground as being one of those places that will prescribe meds off-label," says Eric Roland, senior director of marketing at Legacy.

Michelle felt out of place in her conservative work attire, but found immediate relief when a man at the front desk said he knew about PEP and promptly sent her upstairs to the clinic's education ­department.

Waiting for a consultation, Michelle sat for several minutes watching an anime program about a black man who contracted HIV by having unprotected sex with other men "on the down-low" but hadn't told his pregnant wife.

"The woman sitting next to me — who knows what her story is?" Michelle says. "You feel like passengers on a sinking ship."

Less than three hours after walking into Legacy, Michelle received a prescription for PEP and had it filled at a CVS pharmacy nearby. She began the regimen just before the 72-hour deadline.

When told about Michelle's experience at a local hospital, Roland said: "That makes me really angry. Women have a hard enough time going to ER after an assault. She did what she was supposed to do, and they didn't treat her right."

He then groaned after learning that Michelle went to Memorial Hermann, since Legacy refers all sexual assault victims there.

According to Roland, PEP is not at all well known in the Houston area. He says he has even known healthcare workers exposed to HIV through needles on the job who did not report the incidents because they had never heard about PEP and worried about getting into trouble with their employers.

But even Legacy and other local clinics offering HIV services do little to inform clients about PEP and its potential benefits. Legacy offers no written materials such as brochures or posters regarding PEP. Doctors there may prescribe the medication as rarely as once a month, Roland says.

And the regimen isn't cheap, costing about $800. Many insurance plans do not cover it, and Legacy has no pool of money to draw from to help the indigent with an entire month's supply, Roland says.

Kelly McCann, CEO of AIDS Foundation Houston, says there needs to be a citywide public awareness campaign: "I thought it was common practice to prescribe PEP."

Last week, Michelle's blood tests came back negative for HIV and other sexually transmitted diseases. Since the virus often appears in the bloodstream within the first month after exposure, she was elated.

But she remains angry about the obstacles she faced in getting treatment, and concerned about others in similar ­situations.